Requirement applies to new rates and/or forms filed. (Provide data for sections II, III and IV if the form filing affects rates or benefit structure.)

Provide the SERFF Tracking Number(s) for prior and/or current rate filings related to the form filing within the last 18 months. Include data under the General Information tab in the Filing Description field.

To provide adequate actuarial value information, submit one of the following data sets in your preferred format: (1) Sufficient data for every plan and cost sharing variations to determine the actuarial value or (2) A copy of the actuarial value calculator output page for each plan and cost sharing variation.

*If a carrier plans to offer coverage for child only and/or catastrophic plans, reference the Individual QHPs/EHBs Filing Instructions for On an Exchange and/or Individual EHB Filing Instructions for Off an Exchange and complete requirements as applicable.

*Product filings fees for rates and policy forms must be submitted via Electronic Funds Transfer (EFT) at the time of filing submission. View General Instructions in SERFF for additional details.